On what parts of the scalp do Propecia and Rogaine actually work?
Although their mechanisms of action are different and although Propecia (finasteride) is far more effective than Rogaine (minoxidil) they both work on similar "targets." Both drugs work ONLY on miniaturized hair by increasing their diameter. Neither medication will work on areas that are totally bald i.e. that have no hair. Both work in any areas on the scalp that are subject to androgenetic changes i.e. the front top and crown. The medications work best in the crown where the miniaturization period is more prolonged. However, if there is miniaturization in the front of the scalp (this is particularly seen in younger persons with early hair loss) the medications can regrow hair in this part of the scalp as well. As far as preventing hair loss, they work in all parts of the scalp subject to androgenetic changes. Both medications are far more effective in preventing hair loss rather than "regrowing hair" (i.e. thickening hair once it is extensively miniaturized).
Remember that finasteride is far more effective than minoxidil for both regrowing hair (i.e. thickening miniaturized hair) and preventing hair loss. Their actions do appear to be synergistic and their use together may be advantageous, particularly in young people, although on the long-term it is probably too much of a nuisance to use both. I generally just recommend finasteride for older people or for those considering hair restoration surgery.
Much of the confusion stems from the FDA requirement that claims of pharmaceutical companies regarding their products must be limited to things that were actually tested clinically. Both Upjohn (Rogaine) and Merck (Propecia) did the testing in the crown since this is generally the area of greatest miniaturization and the area most likely to show the most dramatic response. I think that in trying to show effectiveness (a requirement for FDA approval) the drug companies overlooked the importance of frontal hair to a person's appearance. In retrospect, they probably should have done studies both in the front of the scalp and in the crown, even if though the response of the frontal scalp would be less pronounced.
No. It can work all over, as long as the balding is not complete. It has the potential to work wherever there are miniaturized (fine) hairs. It is just that the crown has a longer phase where the hairs are in their transitional state. That is why it is important to treat the front early on.
I heard that Propecia doesn't work in older people, so why should I bother?
It is true that it is less effective in growing hair in older individuals, but a main benefit of Propecia, that of prevention of further loss is just as important.
Once I start Propecia won't I have to use it for life?
Not necessarily. You use it only as long as you want it to work to hold onto your hair. And there will even be better treatments in the future. However, regardless of future medical advances, it will always be much easier to hold onto your hair than to grow it back.
Patients ask to prescribe Proscar. Should I do this?
You should not use and/or break up the 5-mg pills because:
Risk insurance fraud if submitted as medically necessary
Uneven distribution of active ingredient
Uncertain stability if broken up and mixed in a drink
No safety profile if patient takes more
Risk of pregnant woman taking pill
Merck bore the cost of R&D so it is only fair to be able to sell 1mg pill
If a pregnant woman can't even handle the pill how can Propecia possibly be safe?
Since the absorption through the fingertips can't be measured, the FDA considers it all to be absorbed, regardless of how infinitesimal the absorption actually is. If there were really a concern the FDA would require men, taking Propecia to wear condoms when their wife is pregnant, but they do not even recommend this.
I was told to use an herbal 5-alpha reductase inhibitor since it is safer. Is that true?
Unlike food that is best taken as a "natural" substance, medications are taken for a specific problem. Therefore, one should take a form that is pure, where the exact dose is known, where controlled scientific studies have been performed and published in reputable medical journals to show its efficacy and safety, and where other ingredients of unknown safety are not included. It is generally not understood by the lay public that if a herbal form of a medication is taken at a dose that is as effective a medication then the same side effects have the potential to occur.
There are so many non-prescription hair loss products on the market. The ads sound so promising, surely some must work?
Remember, a prescribing physician "usually" has no financial interest in the drug he prescribes. He receives office visit fees from the consult or from performing a surgical procedure. When non-physicians sell products for hair loss they always have a financial interest. There is no other reason for them to manufacture, market and sell their product. More importantly, claims of effectiveness of non-prescription medications are not as strictly regulated by the FDA.
Why can't Propecia be used in post-menopausal women?
The studies using finasteride 1-mg have shown that it is not effective. It may be useful at higher doses, but good studies showing its efficacy and safety still need to be done.
I've heard about all the side effects! What good is having hair if I can't...
The occurrence of sexual dysfunction is only about 1% and it always goes away when you stop the medication. Over half the time it goes away even if you continue using Propecia.
But I don't want to use the medication for a year and then have to stop and have all my hair fall out.
In the occasional case where there are side effects, they seem to mostly appear in the first month or two, long before the effects on the hair begin, so it is easy to stop it without a problem.
What about the new Glaxo medication, Dutasteride?
Combined blockers knock out over 90% of circulating DHT and may have increased side effects as a result. It is not being approved for hair loss. Once it is FDA approved and used for BPH (benign prostatic hypertrophy) we will look at the risk/benefits of this medication closely.
My doctor gave me a combination of Minoxidil and Retin-A in a single solution. Should I use it?
We are generally against the physician-based practice of combining Retin-A with minoxidil. The reason some doctors do this is to get around the law that prevents a doctor, who sells medication in his office, from marking up the price of an individual medication more than 10%. The doctor, however, has the ability to charge anything that he/she wants if he makes his own formulation. If the formulation benefits the patient that is OK, the price might be justified, but in the case of Retin-A/Minoxidil, it is often a scam that actually harms patients.
Here is why: Retin-A only needs to be applied once a day to exert its effects on the skin. That is why Retin-A is prescribed only once a day for acne, where all the other acne medications i.e. topical antibiotics and benzyl peroxide must be used multiple times. Retin-A works by altering the follicular epithelium (the outer layer of skin) so that it doesn't keratinize (form a hard compact layer). This is helpful in acne because it keeps the opening of the follicles from clogging. By preventing keratinization, Retin-A also decreases the protective barrier of the skin and makes it more able to absorb medications (like minoxidil) and more sensitive to chemicals (like the propylene glycol and alcohol base of Rogaine).
Since Retin-A binds well to the skin and exerts it influence over 24 hours, it only needs to be applied once a day. Using it more than once a day causes unnecessary irritation, without increasing its effectiveness. Minoxidil, on the other hand, needs to be used twice a day to be effective. Since the base of minoxidil (the propylene glycol and alcohol) is irritating, minoxidil should not be used more than twice a day.
We are not overly enthusiastic about minoxidil because we do not think that it works well over the long-term and think that it is too fussy. We find that finasteride is far more effective both on the short and long-term. We will occasionally prescribe both to patient with early hair loss that are not yet candidates for a transplant, but for the most part, we use Propecia alone as our mainstay of medical treatment. That said, if patients are set on using minoxidil and want to increase its effectiveness, we suggest that they apply it to damp scalp as soon as they get out of the shower. Applying medication to hydrated (damp) skin can increase the absorption up to 5-fold, without introducing another medication and without causing excessive irritation. It also makes the hair more groomable.
For patients who insist on using Retin-A and minoxidil, we would use them separately and stop the Retin-A as soon as there was any sign off irritation. Remember, irritated skin has very little barrier to absorption, so when you apply medication to irritated skin you are essentially dumping it directly into the blood stream. We know that oral minoxidil is a very potent blood pressure medication that can have very significant adverse side effects of the cardio-vascular system. That is why it is not used either as a first line, or even second line blood pressure medication, but only as a medication for patients with severe hypertension that don't respond to other medications. If a person were not getting irritation, the only local damage would be that the Retin-A would make one more sensitive to the sun (and cause increased facial hair in women). The possible long-term systemic consequences, although probably remote, are unknown. Cardiac enlargement from minoxidil had been reported in a single animal study a number of years ago in England, but did not get much press here. To our knowledge, it has not been duplicated in humans. However, we are always concerned when minoxidil is used with medications that increase its systemic absorb ion such as Retin-A, since we know that minoxidil orally is a very potent and potentially dangerous medication.
The main problem with the combination is that when patients begin to get irritation, they are afraid to stop using the minoxidil for fear of loosing their hair. Since the Retin-A and minoxidil are mixed, they are forced to continue both, i.e. they are in a Catch-22. When they call the prescribing doctor, they are often advised to do things to decrease the irritation, even sometimes to use steroids…but not stop the medication. The doctor doesn't generally give the proper advice and say to simply use over-the-counter minoxidil alone until the irritation subsides and then gradually re-introduce Retin-A as a separate medication a little at a time, since this would uncover the doctor's scam. Therefore, the doctor sticks to his speech about the importance of the combined mixture and the patient is sometimes left with scarring (if the inflammation is not treated properly) and always left with a jacked up bill. (Minoxidil is over-the-counter and very inexpensive and Retin-A just needs to be used very sparingly, no more than once a day. So the cost is very modest.)
We have seen patients that have been given a doctor's mixture of an expensive, in house combination of Retin-A solution (which is very potent) mixed with minoxidil 4%, and told that they must use the combination four times a day. When they got irritation, they were not advised to stop the medication. They continued using this potent medication on an irritated scalp, with the risk of both local scarring (which some actually got) and the risk of systemic toxicity from the increased absorption into the bloodstream.
In sum, the reason we do not like the combination is that it has some potential risk, it increases the irritancy and fussiness of a medication that we do not think is that effective to begin with, and most importantly, it is often abused.
The above information is an educational help only. It is not intended as medical advice for individual conditions or treatments. Talk to Dr. Vafaei before following any medical regimen to see if it is safe and effective for you. This health encyclopedia is made by the Dr. Ali Vafaei . If you want, you can fill the following form and send it to us.Dr. Vafaei will answer your questions regarding Hair Loss and Natural Hair Transplantation soon.